Ms Zorica Pavlovic, Advisor to the Minister of Health of Serbia, welcomed all the participants at the Health Coordination Meeting and thanked them for coming. She underlined to the present agencies that the modus operandi of health related humanitarian assistance coordination with regard to the role of the Ministry of Health of Serbia has not changed. The guidelines distributed earlier this year by the Ministry to humanitarian agencies were still valid. She also announced that in the future the Health Coordination Meetings (HCM) would be held at the Ministry of Health of Serbia once a month, while bilateral meetings with individual agencies would be scheduled upon request by the agencies.
Ms Pavlovic informed that since the last HCM several Memorandums of Understanding (MoU) were signed with international humanitarian agencies. Ms Pavlovic expressed the gratitude for the support provided but reminded that all the projects supported the patronage and home care services, although there were higher priorities in the health service in need of assistance. Ms Pavlovic reminded on the WHO recommendation presented in the Drug Donation Guidelines 1999 – that “when providing relief it is necessary to take into consideration the priorities presented by the recipients”. Ms Pavlovic reminded that the relief programme in Serbia were approved by the Ministry because no other projects were offered and appealed to the present agencies to take into consideration the difficult situation in other services of higher priority and more needed by the population.
In order to present some of the top priorities among the health needs of the population of Serbia, the Ministry invited Prof. Dr Dragan Micic, professor of the Medical Faculty in Belgrade and Deputy Director of the Clinical Centre of Serbia, to give an overview of the situation with regard to the care for patients with diabetes, especially with regard to insulin supply, and an overview of the needs of patients on haemodyalisis and patients with kidney and other organ transplants.

Care for Patients with Diabetes – overview of the current situation in Serbia

Presentation by Prof Dr Dragan Micic

Basic Information

Diabetes is one of the priorities in the health care service in Serbia.

The Law on Health Care of Serbia stipulates that health services for patients with diabetes are free of charge.

The Committee for Diabetes has been established by the Ministry of Health of Serbia.

Organisation of Health Services for Diabetes

There are special ambulantas (dispensaries) within the primary health care system for treatment of patients with diabetes.

The Dispensaries for Diabetes keep district registries of patients with diabetes.

District (general) hospitals provide treatment for patients with diabetes from their catchment area.

Tertiary level services are provided at University hospitals in: Belgrade (Clinic for Endocrinology and Clinic for Diabetes), Nis, Kragujevac and Novi Sad.

The Institute for Endocrinology, Diabetes and Diseases of Metabolism (part of the Clinical Centre of Serbia) is the national reference1 institution for diabetes.

FRY participated in the European Programme for insulin control with the objective that the treatment of insulin patients should be directed towards postponement of complications by adequate blood glucose control and use of insulin without impurities (so called one-peak insulin)

Structure of patients with Diabetes in Serbia

Type I – insulin dependant from the beginning of the disease - 10% of the total number of patients

Type II - 90% of cases, primarily treated by oral hypoglycaemic drugs, but also with insulin.

90% of insulin consumption is by Type II patients - due to the fact that 10-15 years after treatment with oral hypoglycaemic drugs Type II patients become insulin dependent.

The real need for insulin is much higher than that of the needs of the 10% of patients with Type I diabetes.

One-peak insulin is used to reduce the onset of complications (complications begin usually 10 – 15 years after the beginning of treatment with insulin)

Human insulin is used primarily for patients with juvenile diabetes (onset in childhood) in order to prevent allergies against insulin and to achieve best possible blood glucose control.

Insulin supply in Yugoslavia

A diabetes patient without insulin dies within 28 hours.

The local pharmaceutical industry (Galenika and Hemofarm) cover only 10 % of the insulin needs of the country.

The main international suppliers were Novo-Nordisk (Denmark) – 90 %, and Eli-Lilly (USA) – 10 %.

The current supplies are completely irregular and depend exclusively on humanitarian assistance and private purchase by the patients (there is a major shortage of insulin in private pharmacies).

Current problems

Major shortage of insulin, because regular shipments of insulin from Novo-Nordisk have stopped completely due to lack of funds (hard currency) for purchase.

Shortage of syringes and needles (Dilkinson syringes with markings for 40 and 100 I.U. – both used in FRY, are not available on the local market since the NATO air-strikes).

Shortage of sulfonylurea drugs for patients with Type II diabetes – local production cannot cover the needs.

Shortage of metformin drug for patients with a combination of obesity and diabetes (local production cannot cover the needs).

Due to lack of drugs in state pharmacies and delays in reimbursement from the health insurance fund for drugs purchased in private pharmacies patients turn to alternative supply sources (through private advertisements, green – open market, etc. purchasing drugs of dubious quality)

PSF informed that their programme of insulin supply has been completed. It is expected that the programme will continue. PSF informed that there were problems associated with importation of insulin especially with regard to the need of ensuring maintenance of the cold chain during transportation.
MSF Greece informed that they envisaged the project for distribution of insulin (NovoNordisk) directly to hospitals in their area of coverage until the end of 2000. The agency planned to request a continuation of the project from the headquarters.
SITUATION WITH DRUGS FOR PATIENTS WITH ORGAN TRANSPLANTS – IMMUNOSUPPRESSIVE DRUGS

Kidney transplantation are performed in Belgrade, Nis and Novi Sad

There is a central registry of all patients with organ transplants (a total of 500, with around 400 with kidney transplants).

Possibility for action

Handicap International (HI): The agency carried out a survey of the situation in the haemodialysis services (See Belgrade Health Talks No. 15 / 1999). The estimated needs are: one million DEM per month for 3,200 patients at the moment. The programme has not been taken into consideration by any of the donors.

Conclusions

Dr Jukka Pukkila, WHO: Health related humanitarian assistance should concentrate on emergency programmes, particularly supporting life-saving procedures. Taking into consideration that Type I diabetes mellitus is a relatively common chronic disease with life-saving treatment in form of insulin, the programme of insulin supply should be given highest consideration by all agencies who might be able to help in this area.

As a repetition, below please find the priority health needs as presented by the Republic Ministry of Health of Serbia in the Health Coordination Meeting on 25 October 1999:

Haemodialysis: there are two local producers of the needed consumables (Hemofarm and Zdravlje Leskovac). (4,000 patients including IDPs from Kosovo).

1 Reference institution – according to the Decree on the Network of Health Institutions in Serbia a reference institution for a branch of medicine is the leading institution in that field of medicine with scientific and expert basis higher than in any other institution of its kind; it is responsible to define doctrines, protocols and methodology for procedures in its respective branch of medicine and if they are reference institutions for clinical services, also to provide consultation to peripheral institutions and tertiary clinical services or clinical services not available at the peripheral level.